| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
80 |
47 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
266 |
$31K |
| D1110 |
Prophylaxis - adult |
463 |
463 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
178 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
345 |
$11K |
| D0274 |
Bitewings - four radiographic images |
309 |
309 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
190 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
158 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$902.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$300.20 |